Rationale
Hyperglycaemia and insulin resistance occur
commonly in critically ill patients and are associated with an increased risk
of mortality. This may be related to immune compromise, an increased rate of
bacterial growth, and the effects of glycation and free radical production on
protein, lipid and mitochondrial function and integrity.
In
two landmark papers by van den Berghe et al., a combination of tight glucose
control (aiming for blood glucose levels of 4.5–6.1mmol/L) plus additional
glucose and insulin administration reduced mortality and morbidity in both
surgical and medical critical care patients. Benefit was only seen in those
receiving >3–4 days’ therapy.
Controversy
has since existed regarding how tight the glucose control should be, with some
advocating a 5–8mmol/L target range to reduce the risk of potentially injurious
hypoglycaemia, particularly as regular testing introduces a significant nurse
workload. The introduction of (semi-) continuous, (semi-) automated blood
glucose monitoring devices should facilitate closer maintenance of
normoglycaemia.
Protocol
Several protocols and algorithms have been
devised by different groups. None are perfect, but suit the particular circumstances
of their units in terms of staffing levels and expertise.
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